ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (
A) reflects nutritional status, serum potassium level (
C) indicates electrolyte balance, and BUN (
D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
Question 2 of 5
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Establish a plan of care with the client that sets attainable goals. This is because involving the client in setting realistic goals can empower them and increase motivation for rehabilitation. By collaborating with the client, the nurse can address the client's needs and preferences, leading to a more personalized and effective rehabilitation plan. Encouraging the client to actively participate in their care promotes autonomy and fosters a sense of control over their situation.
Other choices are incorrect:
A: Encouraging the client to discuss their feelings is important, but it may not directly address the need for a structured plan of care with attainable goals.
C: Increasing the frequency of physical therapy sessions may be overwhelming for the client and not address the underlying issue of lack of motivation.
D: Allowing the client to set the schedule for rehabilitation may not provide the structure and guidance needed for effective rehabilitation.
Question 3 of 5
A home health nurse assesses an older adult with vision loss due to glaucoma. What is a safety hazard?
Correct Answer: B
Rationale: The correct answer is B: Presence of scatter rugs in the kitchen. Scatter rugs pose a tripping hazard for individuals with vision loss, especially in areas like the kitchen where spills and slippery surfaces are common. The other choices are incorrect because: A - Bright overhead lighting can actually be beneficial for those with vision loss by improving visibility; C - Using contrasting colors can aid in distinguishing objects and pathways; D - Wearing slip-resistant shoes can help prevent falls.
Question 4 of 5
A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Musculoskeletal pain. Anastrozole, an aromatase inhibitor used in breast cancer treatment, can cause musculoskeletal pain as a common adverse effect. This is important to report because severe pain may indicate a more serious condition like osteoporosis or fractures. Headache, nausea, and fatigue are common side effects of anastrozole but usually not considered serious enough to report immediately. Summarily, while all options can occur with anastrozole, musculoskeletal pain warrants prompt reporting due to potential implications on bone health.
Question 5 of 5
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A. Troponin I, Troponin T, CPK, and Myoglobin are all specific laboratory tests used to diagnose a myocardial infarction. Troponin I and T are cardiac biomarkers released into the bloodstream following myocardial cell injury. Creatine phosphokinase (CPK) is an enzyme found in high concentrations in the heart muscle, and elevated levels indicate myocardial damage. Myoglobin is a protein released from damaged muscle cells, including cardiac muscle. These tests provide crucial information to confirm the diagnosis of a myocardial infarction.
Plasma low-density lipoproteins are not specific for diagnosing a myocardial infarction. White blood cell count is not typically used for diagnosing a myocardial infarction, although it may be elevated in response to inflammation associated with heart damage. Blood glucose level is not specific for diagnosing a myocardial infarction and